| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
453 |
283 |
$46K |
| D1120 |
Prophylaxis - child |
922 |
902 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,144 |
1,099 |
$25K |
| D1110 |
Prophylaxis - adult |
412 |
388 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
253 |
153 |
$17K |
| D0272 |
Bitewings - two radiographic images |
446 |
443 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
84 |
84 |
$6K |
| D0274 |
Bitewings - four radiographic images |
267 |
238 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
215 |
215 |
$6K |
| D1206 |
Topical application of fluoride varnish |
535 |
527 |
$5K |
| D1351 |
Sealant - per tooth |
82 |
27 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
12 |
$182.00 |